lecture 66 Flashcards
Ott - pharmacotherapy of ADHD
how does the etiology of ADHD mainfest?
multifactorial so environmental, genetics, and physiological all come into play
higher rate of diagnosis if a first-degree relative also has ADHD
what co-morbid conditions are associated with ADHD?
increased risk of SUD and antisocial personality disorder if ADHD is left untreated
when is it most likely that a person with ADHD will be diagnosed?
usually in childhood
but 1/3 of children will be diagnosed in adulthood
what is the diagnostic criteria for ADHD?
- for each symptom domain, must have at least 6 symptoms present and present in 2 or more settings
- for older adolescents and adults (17+), at least 5 symptoms are required for either of the two specifiers
- severeal inattentive or hyperactive symptoms must be present prior to age 12 years and present in 2 or more settings
how is inattention and hyperactivity/impuslivity defined in ADHD?
six or more of the following symptoms for at least 6 months inconsistent with developmental level and negatively impacting daily functioning
how are stimulants dosed in pediatric patients?
calculating based on mg/kg not found to be helpful as variations in dosing not found to be due to height or weight
for pts weighing under 16kg, what should the stimulants be dosed?
IR preferred due to limited low-dose availability of long-acting stimulants
when should stimulants be given?
avoid giving dose too late in the day (Due to insomnia)
may give an afterschool dose
what stimulant dosage form should be given for late afternoon symptoms?
longer-acting formulations
should two different stimulants be utilized?
no
can use two different dosage form of the same stimulant
when should 12.6 of Mydayis (mixed amphetamine salts) be used?
if pt age 13-17 with a CrCl between 15-30 mL/min
what is the formulation of daytrana (methylphenidate)?
patch
what is unique about vyvanse (lisdexfetamine)?
prodrug that is converted to dextroampetamine via first pass metabolism
what is unique about jornay (methylphenidate HCL)?
take dose in the evening between 6:30pm and 9:30pm
what are the AE of stimulants?
appetite loss
sleep disturbances
decreased growth
increase BP/HR
how would reduced appetite/weight loss be managed?
high-calorie meal when stimulant effects are low (breakfast, dinner)
how would insomnia be managed?
dose earlier in the day
lower last dose of day or give earlier
consider sedating med at bedtime
how should rebound symptoms be managed?
longer-acting stimulant trial
atomoxetine
antidepressants
how should increased BP/HR be managed?
reduce dose
change stimulant
how should hallucinations be managed?
d/c stimulant
reassess diagnosis
how should risk for sudden cardiac death be managed?
risk no greater in clinical trials than general population
ass risk of cardiac structural abnormality and family hx
if concern, cardiac echo
what should be monitored in stimulants?
appetite
behavior
BP
growth rate (height/weight)
HR
sleep ECG may be considered based on cardiac risk
what drugs are alpha 2 agonists?
guanfacine ER
clonidine ER
what is important to note about alpha 2 agonists?
must be tapered if d/c to avoid rebound HTN
guanfacine ER is a 3A4 substrate
what drugs are NE reuptake inhibitors?
atomoxetine
viloxazine
what is important to note about atomoxetine?
2D6 substrate
has weight based dosing for over an dunder 70 kg
what is important to note about viloxazine?
capsules that need to be swallowed whole or put in applesauce
2D6/UGT substrate and strong 1A2 inhibitor
what are the AE of NE reuptake inhibitors?
increase HR/BP
increase in suicidal thinking (BW)
what are the SE of alpha 2 agonists?
decrease HR/BP, orthostasis
somnolence
dizziness
rebound HTN if abrupt D/c
what drug classes make up non-stimulants?
alpha 2 agonists
NE reuptake inhibitors
what are monitoring parameters for non-stimulants?
appetite
BP
HR
LFTs (atomoxetine only)
what are important CP of bupropion?
not FDA-approved for ADHD
2D6 inhibitor
CI in seizure disorders and eating disorders
what are important CP of TCAs?
less effective than methylphenidate
cardiac concerns - sudden cardiac death in children, lethal in overdose
what is important to note about using mood stabilizer/atypical antipsychotics in ADHD therapy?
may be useful if there is comorbid BPD, conduct disorder, or intermittent explosive disorder
should not use as monotherapy to treat ADHD
what is the first line treatment according to the AAP for preschool age children?
methylphenidate
what is the treatment guidelines according to the AAP for elementary/middle school/adolescent?
first line – stimulants
second-line – atomoxetine, guanfacine ER, clonidine ER
what is the AAP recommendation for adjunctive treatment?
only guanfacine ER and clonidine ER have evidence as adjunct to stimulants
what is the NICE:ADHD guidelines 2018 for adults?
use Methylphenidate OR lidexamfetamine
then trial dextroamphetamine
then atomoxetine if no response
